Greenslopes Obstetrics & Gynaecology: Dr Ken Law - Fertility

FERTILITY & IVF Dr Ken Law

MBBS (Hons 1), FRANZCOG Obstetrician and Gynaecologist - Greenslopes Private Hospital Fertility Specialists - Care Fertility Senior Lecturer - The University of Queensland

Patient Information

P 07 3188 5000 | F 07 3188 5050 info@gsog.com.au Suite 7.101, Level 7, Nicholson Street Specialist Centre 83 Nicholson St, Greenslopes Qld 4120 gsog.com.au

Patient Information

P 07 3188 5000 | F 07 3188 5050 info@gsog.com.au Suite 7.101, Level 7, Nicholson Street Specialist Centre 83 Nicholson St, Greenslopes Qld 4120 gsog.com.au

Fibroids

P 07 3188 5000 | F 07 3188 5050 info@gsog.com.au Suite 7.101, Level 7, Nicholson Street Specialist Centre 83 Nicholson St, Greenslopes Qld 4120 gsog.com.au

Endometriosis

P 07 3188 5000 | F 07 3188 5050 info@gsog.com.au Suite 7.101, Level 7, Nicholson Street Specialist Centre 83 Nicholson St, Greenslopes Qld 4120 gsog.com.au

Patient Information

P 07 3188 5000 | F 07 3188 5050 info@gsog.com.au Suite 7.101, Level 7, Nicholson Street Specialist Centre 83 Nicholson St, Greenslopes Qld 4120 gsog.com.au

Patient Information

ICSI (Intracytoplasmic Sperm Injection)

P 07 3188 5000 | F 07 3188 5050 info@gsog.com.au Suite 7.101, Level 7, Nicholson Street Specialist Centre 83 Nicholson St, Greenslopes Qld 4120 gsog.com.au

Patient Information

DAY 1

DAY 2

DAY 3

P 07 3188 5000 | F 07 3188 5050 info@gsog.com.au Suite 7.101, Level 7, Nicholson Street Specialist Centre 83 Nicholson St, Greenslopes Qld 4120 gsog.com.au

Embryo Transfer

Frozen Embryo(s)

P 07 3188 5000 | F 07 3188 5050 info@gsog.com.au Suite 7.101, Level 7, Nicholson Street Specialist Centre 83 Nicholson St, Greenslopes Qld 4120 gsog.com.au

Pregnancy Test

Ultrasound

P 07 3188 5000 | F 07 3188 5050 info@gsog.com.au Suite 7.101, Level 7, Nicholson Street Specialist Centre 83 Nicholson St, Greenslopes Qld 4120 gsog.com.au

Patient Information

P 07 3188 5000 | F 07 3188 5050 info@gsog.com.au Suite 7.101, Level 7, Nicholson Street Specialist Centre 83 Nicholson St, Greenslopes Qld 4120 gsog.com.au

Letrozole Unexplained Infertility • • • •

2 years of regular unprotected sexual intercourse Normal semen analysis Normal Laparoscopy and tubes (inc. mild or minimal endometriosis) Ovulatory cycles Clinical Pregnancy Rate* per cycle

Cost per cycle

Expectant Management

1-2%

$0

Clomiphene or Letrozole

2-3%

$40

Clomiphene + Insemination (IUI)

6%

$200

FSH + Insemination (IUI)

8-13%

$400

IVF

38%

$2500

Intervention

* fetal heart activity confirmed at 6 weeks gestation.

Letrozole (Femara TM) Side Effects Letrozole is well tolerated by most women. It was not designed as a fertility medication, and it is mainly used to treat certain types of breast cancers.

• • • • • •

Hot flushes (common) Abdominal pain and distension Fatigue, Joint/Muscle pain, Hair loss, Swelling Difficulty sleeping, Sweating Nausea and vomiting Breast tenderness

Complications • • •

Twins (4%) Triplets (0.5%), Quadruplets (0.3%), Quintuplets (0.12%) Servere skin reactions (rare)

Dosage • • • • •

Take on day 3 to day 7 menstrual cycle (N.B. “day 1 of menstrual cycle” is first day of menstrual bleeding) Dosage: 2.5mg per day A blood test (for Progesterone level) is performed 7 days prior to the next expected menses to check for ovulation (e.g. day 21 in a 28 day cycle) Re-evaluate if conception has not occurred after 2-3 cycles Maximum 6 cycles P 07 3188 5000 | F 07 3188 5050 info@gsog.com.au Suite 7.101, Level 7, Nicholson Street Specialist Centre 83 Nicholson St, Greenslopes Qld 4120 gsog.com.au

Clomiphene Unexplained Infertility • • • •

2 years of regular unprotected sexual intercourse Normal semen analysis Normal Laparoscopy and tubes (inc. mild or minimal endometriosis) Ovulatory cycles Clinical Pregnancy Rate* per cycle

Cost per cycle

Expectant Management

1-2%

$0

Clomiphene

2-3%

$40

Clomiphene + IUI

6%

$200

FSH + IUI

8-13%

$400

IVF

38%

$2500

Intervention

* fetal heart activity confirmed at 6 weeks gestation.

Clomiphene (Clomid) Side Effects Clomiphene is well tolerated by most women.

• • • •

Hot flushes (10-20%) Abdominal pain and distension (5.5%) Nausea and vomiting (2%) Breast tenderness (2%)

Complications • • •

Twins (7-9%) Triplets (0.5%), Quadruplets (0.3%), Quintuplets (0.13%) Visual problems (e.g. double vision), usually reversible after cessation of therapy.

Dosage • • • • •

Take on day 3 to day 7 menstrual cycle (N.B. “day 1 of menstrual cycle” is first day of menstrual bleeding) Dosage: 50mg per day A blood test (for Progesterone level) is performed 7 days prior to the next expected menses to check for ovulation (e.g. day 21 in a 28 day cycle) Re-evaluate if conception has not occurred after 2-3 cycles Maximum 6 cycles

P 07 3188 5000 | F 07 3188 5050 info@gsog.com.au Suite 7.101, Level 7, Nicholson Street Specialist Centre 83 Nicholson St, Greenslopes Qld 4120 gsog.com.au

ANTI-MULLERIAN HORMONE (AMH) BLOOD TEST

What is Ovarian Reserve Ovarian reserve refers to the number and quality of eggs in a woman’s ovaries. At birth, a woman has around one million eggs, and over her reproductive years, this number decreases due to natural attrition and ovulation, with approximately 400 eggs lost through ovulation itself. The remaining decrease happens due to natural cell death (apotheosis).

Individual rates of egg loss through apotheosis vary, impacting the age at which menopause occurs.

However, about 10 percent of women experience accelerated egg loss, leading to a significant reduction in ovarian reserve by their mid-thirties.

What is Anti-Millerian Hormone (AMH)?

AMH is a hormone created by granulosa cells in early-stage antral follicles, representing developing immature eggs. When a woman’s egg supply diminishes, the count of these small follicles decreases, causing a drop in serum AMH levels. This decline in AMH serves as a reliable indicator of the remaining egg count.

How do you identify women with diminished Ovarian Reserve?

Women with a family history of early menopause, prior ovary surgery, severe endometriosis, or past chemotherapy/radiation face higher risks of diminished ovarian reserve. However, most cases occur without these risk factors. Such women might have regular menstrual cycles and apparent signs of ovulation via luteal phase progesterone analysis. Identifying this group relies on ovarian reserve testing as there may be no evident symptoms otherwise.

How do we assess Ovarian Reserve The ideal method for assessing ovarian reserve involves a blend of serum hormone tests (FSH, Anti-Mullerian hormone) and pelvic ultrasound (antral follicle count, ovarian volume), termed the ‘Egg Timer’ at Repromed. However, Anti-Mullerian hormone stands out as the most sensitive part of this assessment and can serve as an initial screening test for ovarian reserve on its own.

Why is Ovarian Reserve assessment important?

Women facing diminished ovarian reserve experience reduced fertility and a higher risk of miscarriage. Early identification is crucial, enabling informed family planning decisions and timely access to assisted reproductive technology if needed.

P 07 3188 5000 | F 07 3188 5050 info@gsog.com.au Suite 7.101, Level 7, Nicholson Street Specialist Centre 83 Nicholson St, Greenslopes Qld 4120 gsog.com.au

ANTI-MILLERIAN HORMONE (AMH) BLOOD TEST Who should have Ovarian Reserve testing?

Women under 38 years, considering postponing pregnancy, benefit most from ovarian reserve testing. Identifying diminished reserve helps advance family planning, boosting success chances.

However, women above 40 typically have diminished reserve, discouraging delayed pregnancy regardless of ‘Egg Timer’ results.

Lastly, those at risk, like those with family history of ovarian failure, autoimmune disease, prior ovarian surgery, or chemotherapy, also benefit from ovarian reserve testing.

How do I arrange for Ovarian Reserve testing?

Patients can get an AMH test by requesting it on a Repromed pathology form, which can be sent to doctors’ offices by contacting Repromed. Samples can be collected at Repromed or any Clinpath Collection center in SA. Alternatively, doctors can request AMH through their preferred pathology provider, sending it to Repromed in Adelaide, but this might cause a delay in results. Normal range data for AMH at Repromed is specific to their analysis method. Also, interstate samples are collected weekly, frozen, and then sent.

What is the cost of Ovarian Reserve testing?

AMH testing lacks a Medicare item number, costing $60 per test. In SA, the complete ‘Egg Timer’ test with a written report costs $230. Patients from other states can access this service, but costs differ, including ultrasound and potential transportation expenses. Contact for state-specific details.

At what time in the menstrual cycles should AMH be taken?

Unlike serum FSH, Anti-Mullerian hormone levels show minimal fluctuation throughout the menstrual cycle, allowing testing at any point during it.

How do I interpret the Anti-Millerian hormone result?

Research at Repromed indicates that women with serum Anti-Mullerian hormone levels equal to or less than 14 pmol/L face reduced success in IVF programs and higher miscarriage risks. This value is crucial in assessing ovarian reserve. Repromed’s study of over 800 women established normal percentile ranges, depicted in the accompanying graph. Those in the lowest quartile (<25%) with AMH levels below 14 pmol/L often have diminished ovarian reserve. Conversely, women in the upper quartile (>75%) are more likely to have polycystic ovarian syndrome (PCOS). AMH serves as a reliable marker for PCOS.

P 07 3188 5000 | F 07 3188 5050 info@gsog.com.au Suite 7.101, Level 7, Nicholson Street Specialist Centre 83 Nicholson St, Greenslopes Qld 4120 gsog.com.au

ANTI-MILLERIAN HORMONE (AMH) BLOOD TEST

What can be done if a women is found to have a low Ovarian Reserve?

Women cannot generate more eggs after birth, making it impossible to expand the oocyte reserve.

The most effective approach is for women to advance their family planning, which significantly influences the success of the ‘Egg Timer’ test.

In instances where a woman has a low ovarian reserve and hasn’t conceived within six months of trying, early investigation for infertility is recommended. If a severe male factor is identified, early referral for IVF might aid in conception.

P 07 3188 5000 | F 07 3188 5050 info@gsog.com.au Suite 7.101, Level 7, Nicholson Street Specialist Centre 83 Nicholson St, Greenslopes Qld 4120 gsog.com.au

ANTI-MILLERIAN HORMONE (AMH) BLOOD TEST

P 07 3188 5000 | F 07 3188 5050 info@gsog.com.au Suite 7.101, Level 7, Nicholson Street Specialist Centre 83 Nicholson St, Greenslopes Qld 4120 gsog.com.au

P 07 3188 5000 | F 07 3188 5050 info@gsog.com.au Suite 7.101, Level 7, Nicholson Street Specialist Centre 83 Nicholson St, Greenslopes Qld 4120 gsog.com.au

Anatomy of the Female Pelvic Organs

P 07 3188 5000 | F 07 3188 5050 info@gsog.com.au Suite 7.101, Level 7, Nicholson Street Specialist Centre 83 Nicholson St, Greenslopes Qld 4120 gsog.com.au

Anatomy of the Female Pelvic Floor

P 07 3188 5000 | F 07 3188 5050 info@gsog.com.au Suite 7.101, Level 7, Nicholson Street Specialist Centre 83 Nicholson St, Greenslopes Qld 4120 gsog.com.au

Costs of IVF Cycles & Extended Medicare Safety Net Having treatment for infertility may involve IVF, ICSI, FET. These are often called ‘treatment cycles’, as each treatment, usually conducted over the period of a month, gives a couple an improved change of conception compared to a natural menstrual cycle.

In Australia, for residents who hold a Medicare card, a significant part of the treatment is funded by Medicare. If a couple or family have exceeded the Extended Medicare Safety Net (EMSN) within a calendar year, the rebates from Medicare are significantly higher, because Medicare will then pay 85% of all out of pocket expenses for services which there is a Medicare item number. You can find out whether you family has reached the EMSN for this calendar year Medicare Online. The EMSN applies from 1 January until 31 December of each year.

Private hospital insurance only covers a relatively small part of the IVF treatment costs as private hospital insurance only covers a relatively small part of the IVF treatment costs, as private hospital insurance only covers the hospital admission/theatre costs, and part of the in-hospital procedural fees. These in-hospital procedures include the oocyte (egg0 collection and embryo transfer Procedure.

The OOP expenses listed below do not include any extra drugs, storage costs, freezing costs and adjunctive treatments (such as use of ‘Embryo Glue’, assisted hatching, special culture media).

With Private Hospital Insurance Covering Fertility Treatments - Approx. Out of Pocket Cost per Cycle: Before EMSN Reached

After EMSN Reached

IVF

$3409

$1507

ICSI

$3878

$1868

FET

$2079

$1150

Without Private Hospital Insurance Covering Fertility Treatments -Approx. Out of Pocket Cost per Cycle: Before EMSN Reached

After EMSN Reached

IVF

$4162

$2188

ICSI

$4679

$2550

FET

$2271

$1293

The above tables are only an approximate indication to illustrate the effect on Our of Pocket Costs due to the Extended Medicare Safety Net (EMSN) and whether Private Hospital Insurance cover s available. For a breakdown of costs per cycle base on your individual circumstances, please refer to the itemised fee schedule.

P 07 3188 5000 | F 07 3188 5050 info@gsog.com.au Suite 7.101, Level 7, Nicholson Street Specialist Centre 83 Nicholson St, Greenslopes Qld 4120 gsog.com.au

P 07 3188 5000 | F 07 3188 5050 info@gsog.com.au Suite 7.101, Level 7, Nicholson Street Specialist Centre 83 Nicholson St, Greenslopes Qld 4120 gsog.com.au

Informed Financial Consent Consultation & Outpatient Procedure Fees Patients have the right to know how much their private health care will cost. At Greenslopes Obstetrics & Gynaecology, we will always strive to provide full and transparent financial disclosure. Below is a list of our basic consultation fees for Gynaecology services. This list does not include all services provided by our practice and does not include inpatient surgical procedures. Any patient requiring an inpatient surgical procedure will be provided with a full Estimate of Surgical Fees following consultation and assessment with one of our doctors.

Gynaecology

FEE

MEDICARE REBATE

OUT OF POCKET

Gynaecology Consultation with New Referral*

$330

$80.85

$249.15

Follow-up Gynaecology Consultation

$150

$40.65

$109.35

Fertility

FEE

MEDICARE REBATE

OUT OF POCKET

Initial Fertility Consultation for each partner

$330

$80.85

$249.15

Follow-up Fertility Consultation

$150

$40.65

$109.35

Planning & Management of IVF or IUI cycle

$360

$78.85

$281.15

Associated Medical Procedures

FEE

MEDICARE REBATE

OUT OF POCKET

Insertion of IUD (Mirena, Kyleena, Cooper)

$230

$74.65

$155.35

Removal of IUD (Mirena, Kyleena, Cooper)

$80

-

$80

Endometrial Biopsy

$176

$49.70

$126.30

Colposcopy/Vulvoscopy

$230

$59.50

$170.50

Cervical Biopsy in conjunction with Colposcopy

$297

$89.30

$207.70

Cervical/Vaginal Polyp Removal

$182

$59.55

$122.45

Vulval Biopsy in conjunction with Vulvoscopy

$297

$89.30

$207.70

Vulval Biopsy

$250

$65.55

$184.45

Implanon Insertion

$130

$33.15

$96.85

Implanon Removal

$180

$56.55

$123.45

Insertion of Zoladex Implant

$84

$33.15

$50.85

Vaginal Pessary for Prolapse

$67.50

-

$67.50

Pudendal Nerve Block

$298

$93.90

$204.10

Penthrox (‘Green Whistle’)

$80

-

$80 P 07 3188 5000 | F 07 3188 5050

Not all in-office procedures available are listed above. Fees for info@gsog.com.au any additional services not listed above (e.g. ultrasounds) will be Suite 7.101, Level 7, Nicholson Street Specialist Centre advised at time of consultation83 byNicholson your specialist.

St, Greenslopes Qld 4120 gsog.com.au

Informed Financial Consent Fertility Management & Procedure Fees The fees outlined below are payable at Greenslopes Obstetrics and Gynaecology. It is separate from the fees payable at Care Fertility, which are outlined in the Fee Schedule from Care Fertility.

IVF

FEE

MEDICARE REBATE

OUT OF POCKET

Planning & Management of IVF or ICSI Cycle (13029)

$360

$76.15

$283.85

Follow-up Consultation After Completion of IVF Cycle

$135

$39.25

$95.75

Egg Pickup & Embryo Transfer

FEE

MEDICARE REBATE

KNOWN GAP (IF INSURED)

Egg Pickup (13212)

$1080

$318.50

$500

Embryo Transfer (13215)

$340

$99.90

$130

Intrauterine Insemination

FEE

MEDICARE REBATE

OUT OF POCKET

Planning & Management of IUI Cycle (13209)

$360

$76.15

$283.85

IUI Cycle Global Fee (13203) (Includes scans/bloods during the cycle, and the insemination procedure)

$1485

$437.40

$1047.60

Once you reach the Extended Medical Safety Net threshold in a calendar year, you may receive a higher Medicare rebate for Outpatient Services.

P 07 3188 5000 | F 07 3188 5050 info@gsog.com.au Suite 7.101, Level 7, Nicholson Street Specialist Centre 83 Nicholson St, Greenslopes Qld 4120 gsog.com.au

P 07 3188 5000 | F 07 3188 5050 info@gsog.com.au Suite 7.101, Level 7, Nicholson Street Specialist Centre 83 Nicholson St, Greenslopes Qld 4120 gsog.com.au